Summary of Benefits and Coverage: What this Plan covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Ambetter from New Hampshire Healthy Families : Ambetter Secure Care 1 (2018) with 3 Free PCP Visits Coverage for: Individual/Family Plan Type: EPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit https://ambetter.nhhealthyfamilies.com/2018-brochures.html, or call 1-844-265-1278 (TTY/TDD 1-855-742-0123). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-844-265-1278 (TTY/TDD 1-855-742-0123) to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-ofpocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? $1,000 individual/$2,000 family. Yes. Preventive care and generic drugs are covered before you meet your deductible. Yes, $500 individual/$1,000 family for drug expenses. There are no other specific deductibles. For network provider $6,350 individual/$12,700 family. No, for non-network providers. Premiums, balance-billing charges, and health care this plan doesn t cover. Yes. See Find a Provider or call 1-844-265-1278 for a list of network providers. No. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don t count toward the out of pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. SBC-75841NH0090001-01 Gold - Underwritten by Celtic Insurance Company 1 of 7
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider's office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Coinsurance Not covered Specialist visit Coinsurance Not covered Preventive care/ screening/ immunization Network Provider (You will pay the least) No charge What You will Pay Out-of-Network Provider (You will pay the most) Not covered Limitation, Exceptions, & Other Important Information 3 free visits per person, 4th visit and after subject to Deductible and Coinsurance. Your 3 free visits apply only to the provider s fee for the evaluation and management service. All other eligible services are subject to Deductible and Coinsurance. The 3 free office visits can include a combination of PCP, Other Practitioner, Mental/Behavioral and Substance Abuse Disorder office visits. Prior authorization required. Failure to obtain prior authorization for any service that requires prior authorization may result in reduction of benefits. See your policy for details You may have to pay for services that aren t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood work) Coinsurance Not covered Prior authorization required. Imaging(CT/PET scans, MRIs) Coinsurance Not covered Prior authorization required. 2 of 7
Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Preferred Drug List. If you have outpatient surgery If you need immediate medical attention Services You May Need Generic Drugs (Tier 1) Preferred brand drugs (Tier 2) Non-preferred brand drugs (Tier 3) Specialty drugs (Tier 4) Network Provider (You will pay the least) Retail: $10 Mail order: $30 deductible does not apply Retail: $25 Mail order: $75 Subject to Rx deductible Retail: $75 Mail order: $225 Subject to Rx deductible 30% Coinsurance; Subject to Rx deductible What You will Pay Out-of-Network Provider (You will pay the most) Not covered Not covered Not covered Not covered Limitation, Exceptions, & Other Important Information Prescription drugs are provided up to 31 days retail and up to 90 days through mail order. Mail orders are subject to 3X retail cost-sharing amount. Prior authorization required. $500 individual/$1,000 family Rx drug deductible for preferred brand, nonpreferred brand and specialty drugs. Prescription drugs are provided for up to 31 days retail and up to 90 days through mail order. Mail orders are subject to 3X retail cost-sharing amount. Prior authorization required. $500 individual/$1,000 family Rx drug deductible for preferred brand, nonpreferred brand and specialty drugs. Prescription drugs are provided for up to 31 days retail and up to 90 days through mail order. Mail orders are subject to 3X retail cost-sharing amount. Prior authorization required. $500 individual/$1,000 family Rx drug deductible for preferred brand, nonpreferred brand and specialty drugs. Prescription drugs are provided for up to 31 days retail and up to 90 days through mail order. Mail orders are subject to 3X retail cost-sharing amount. Facility fee (e.g., ambulatory surgery center) Coinsurance Not covered Prior authorization required. Physician/surgeon fees Coinsurance Not covered Prior authorization required. Emergency room care $250 Copay/visit $250 Copay/visit -----None----- Emergency Medical transportation Coinsurance Coinsurance -----None----- Urgent Care Coinsurance Not covered -----None----- 3 of 7
Common Medical Event If you have a hospital stay If you need mental health, behavioral health, or substance abuse services If you are pregnant Services You May Need Limitation, Exceptions, & Other Important Information Facility fee (e.g., hospital room) Coinsurance Not covered Prior authorization required. Physician/surgeon fees Coinsurance Not covered Prior authorization required. Prior authorization required. (PCP and Other Practitioner visits do not require prior authorization). 3 free visits per person, 4th visit and after subject to Deductible and Coinsurance. Your 3 free visits apply only to the provider s fee for the Outpatient services Coinsurance Not covered evaluation and management service. All other eligible services are subject to Deductible and Coinsurance. The 3 free office visits can include a combination of PCP, Other Practitioner, Mental/Behavioral and Substance Abuse Disorder office visits. Inpatient services Coinsurance Not covered Prior authorization required. Prior authorization required, except office visits. Cost sharing does not apply for preventive services. Depending on the type of services, Office visits Coinsurance Not covered coinsurance, copayment and/or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Prior authorization required, except office visits. Cost sharing does not apply for preventive services. Depending on the type of services, Childbirth/delivery Coinsurance Not covered coinsurance, copayment and/or deductible may professional services apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery facility services Network Provider (You will pay the least) What You will Pay Out-of-Network Provider (You will pay the most) Coinsurance Not covered Prior authorization required, except office visits. Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance, copayment and/or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). 4 of 7
ultrasound). 5 of 7
Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Network Provider (You will pay the least) What You will Pay Out-of-Network Provider (You will pay the most) Limitation, Exceptions, & Other Important Information Home health care Coinsurance Not covered Prior authorization required. Rehabilitation services Coinsurance Not covered Prior authorization required. 20 visits per year per therapy (OT, ST and PT). Habilitation services Coinsurance Not covered Prior authorization required. 20 visits per year per therapy (OT, ST and PT). Skilled nursing care Coinsurance Not covered Prior authorization required. 100 days per year in a facility. Durable medical equipment Coinsurance Not covered Prior authorization required. Hospice services Coinsurance Not covered Prior authorization required. $0 Copay/visit; Children's eye exam deductible does not Not covered 1 Visit per Year apply $0 Copay/item; Children's glasses deductible does not Not covered 1 Item per Year apply Children's dental check-up Not covered Not covered -----None----- Excluded Services & Other Covered Services Services your Plan Generally Does NOT cover (Check your policy or plan documentation for more information and a list of any other excluded services.) Abortion (Except in cases of rape, incest, or Acupuncture Cosmetic surgery when the life of the mother is endangered) Dental Care Long-term care Non-emergency care when traveling outside the Private-duty nursing Routine eye care (Adult) U.S. Weight loss programs 6 of 7
Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) Bariatric surgery Chiropractic care (Limited to 12 specialists visits per year) Hearing aids Infertility treatment (See policy for coverage details) Routine foot care (Related to diabetes treatment) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: New Hampshire Insurance Department, 21 South Fruit Street, Suite 14, Concord, NH 03301, Phone No. 800-852-3416. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.healthcare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: New Hampshire Insurance Department, 21 South Fruit Street, Suite 14, Concord, NH 03301, Phone No. 800-852-3416. Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-844-265-1278, TTY/TDD 1-855-742-0123. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-844-265-1278, TTY/TDD 1-855-742-0123. Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 1-844-265-1278, TTY/TDD 1-855-742-0123. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne 1-844-265-1278, TTY/TDD 1-855-742-0123. To see examples of how this plan might cover costs for a sample medical situation, see the next section. 7 of 7
About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage Peg is Having a baby (9 months of in-network pre-natal care and a hospital delivery) The plan's overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance $1,000 This EXAMPLE even includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery facility Services Diagnostic test (ultrasounds and blood work) Specialist visit (anesthesia) Managing Joe's type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) The plan's overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance $1,000 This EXAMPLE even includes services like: Primary care physician office visits (includes disease education) Diagnostic tests (blood work) Prescription Drugs Durable medical equipment (glucose meter) Mia's Simple Fracture (in-network emergency room visit and follow up care) The plan's overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance $1,000 This EXAMPLE even includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (Physical therapy) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles $1,000 Copayments $40 Coinsurance $2,500 What isn't covered Limits or exclusions $60 The total Peg would pay is $3,600 Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles* $1,500 Copayments $600 Coinsurance $600 What isn't covered Limits or exclusions $60 The total Joe would pay is $2,760 Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $1,000 Copayments $0 Coinsurance $400 What isn't covered Limits or exclusions $0 The total Mia would pay is $1,400 *Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services? row above. The plan would be responsible for the other costs of these EXAMPLE covered services.